Gout

A sudden, severe attack — most classically the base of the big toe — with a joint that is red, hot, swollen and exquisitely painful, often waking the person at night. A typical attack reaches its peak in less than 24 hours 2.

A single hot swollen joint can also be septic arthritis, an emergency infection that can rapidly damage the joint. UK guidance calls for immediate referral whenever it is suspected 1. The two can look identical and the distinction is made by joint aspiration, not by assumption.

Gout is the most treatable form of inflammatory arthritis. Urate-lowering therapy taken continuously, titrated to a target serum urate level, prevents attacks and dissolves existing crystal deposits over time.

Despite that, adherence is poor and long-term control is often not achieved — frequently because treatment is started during an attack, stopped when it settles, and never titrated to target.

During an attack: rest, protection and pain management, not exercise. Between attacks: restoring range and strength in joints affected by repeated inflammation, gait retraining where the foot or knee has been involved, and footwear advice.

In long-standing gout with tophi and joint damage, function-focused rehabilitation and joint protection matter as much as in other forms of arthritis.

There is not enough evidence that any specific diet prevents flares or lowers serum urate, so diet is not a substitute for medication in established gout 1. Weight management, reducing alcohol — particularly beer — and reducing sugar-sweetened drinks all help at the margin.

We say this plainly because patients are frequently given a restrictive diet instead of adequate medical treatment, and then blamed when attacks continue.

During an acute attack the joint is not exercised — it is rested, elevated and treated medically. Movement is reintroduced as inflammation settles.

The rehabilitation work happens between attacks: restoring range and strength lost during them, and addressing the weight, activity and cardiovascular risk that accompany the condition.

Urate-lowering medicine is started at a low dose and increased step by step, guided by monthly blood tests, until serum urate is below 360 micromol/litre (6 mg/dl) 1. A lower target, below 300 micromol/litre (5 mg/dl), is considered for people with tophi, chronic gouty arthritis or continuing flares, and once the target is reached treatment usually continues for life 1.

Starting treatment can itself trigger flares, so guidance recommends preventive anti-inflammatory medicine for at least three to six months 3. UK guidance offers colchicine first for this 1. Losing excess weight is also recommended for people who are overweight 3. But only keeping urate below target clears the crystals, so exercise, weight loss and diet support the plan without replacing it 1.